Healthcare Provider Details

I. General information

NPI: 1780241398
Provider Name (Legal Business Name): MINI SUSAN MAMMEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E SHORE RD
GREAT NECK NY
11023-2410
US

IV. Provider business mailing address

475 BEECH ST
NEW HYDE PARK NY
11040-3825
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-8657
  • Fax:
Mailing address:
  • Phone: 718-598-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberF344251
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF344251
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: